The Right to Decent Health

Mothers in Burkina Faso call the first rainfall in May the rains of hope. That is because it signals the end—for one year—of the epidemic that steals so many of their children.

But when the dry season comes again, and mothers from Senegal to Ethiopia brace themselves for the epidemic’s return, there will be relief from the usual terror. Finally, a meningitis A vaccine has been developed at a low enough cost for poor countries to afford. In an enormously successful mass vaccination campaign, millions have received the shot that will save them from an untimely death or prevent them from becoming so disabled that they cannot feed their families.

The international effort that achieved this is nothing short of a miracle, in the view of many global health experts—and it is one in which F. Marc LaForce ʼ60 has played a vital role. The New Hampshire native has spent the past decade helping to break the deadly lock that bacterial meningitis has had on Africa’s poorest countries.

In a career that is in its fifth decade, Marc LaForce has been a malaria tracker, a “smallpox warrior,” a professor, clinician, researcher, administrator, and fund raiser. His work has taken him from New Mexico to the Mekong River to remote African villages, as well as to the halls of academe and the World Health Organization (WHO). These days, he is likely to be found at the podium addressing an international meningitis conference in London or teaching an advanced level vaccinology course in India.

His official role is director of the Meningitis Vaccine Project at the Seattle-based nonprofit PATH (Program for Appropriate Technology for Health); but his path to PATH is not one he ever envisioned.

LaForce’s interest in medicine began because he needed an after-school job. His father had died, leaving six children to be raised by their mother. “Everybody worked,” he says. At 15, he got a job at Precourt’s Pharmacy in East Manchester. He kept it while majoring in chemistry at Saint Anselm, where he and his two brothers, Louis ’63 and Pierre ’57, were “day hops.” He loved chemistry and was tempted to take the Ph.D. route into medical research; but his experience at the local drug store led him to choose the challenge of treating patients.

After earning an M.D. at Seton Hall College of Medicine, LaForce trained on the Harvard Medical Unit at Boston City Hospital, a public hospital for the poor. When he was drafted to serve in Vietnam, the doctor in charge of the Harvard Medical Service requested that he be allowed to work for the federal CDC (Centers for Disease Control) instead. He was sent to a Navajo Reservation where there was an outbreak of Bubonic plague.

“I’d never traveled further than New Jersey, and then one day I found myself in my Florsheim shoes in the middle of an Indian reservation,” he recalls. Over the next two years as an epidemic intelligence officer, his assignments included working on the Malaria Eradication Program in Thailand and a plague outbreak in Nepal.

“It became clear to me that there was so much we could do with the resources that we take for granted,” he says. The experience also taught him that he could work in pretty much any environment. He slept on floors and tables, and often in his Land Rover.

That was only the beginning, of course. He looks back on competing with rats for his rations; coming home with large tape- worms; checking under his bed for snakes; wearing boots to avoid flea- bitten ankles; and running from elephants. And frequent dysentery, no matter what precautions are taken. He holds an enduring image of a carpet of rats fleeing a famine-stricken island in the Brahmaputra River.

But he calls it “terribly interesting,” enjoyable and challenging. None of it seems to bother him nearly as much as the dreary inconveniences of modern business travel. “I despise traveling,” says the world traveler. Putting up with all this is part of what makes a good field worker, which is the highest praise for people in LaForce’s line of work.

“If people couldn’t say that about me, I’d quit,” he says.

The Smallpox Warrior

LaForce returned to Harvard to finish his training in infectious disease, but kept ties with the CDC. When new cases of smallpox began occurring in India in December 1974, his CDC mentor, Dr. Philip Brachman, then head of the epidemiology group (now known for his work with anthrax), asked him to lend a hand. It would mean being in the field for three or four months at a time. By then, LaForce was married to Nancy Collins, a nurse he’d met at City Hospital.

“I said I’d never hold him back. I said ‘Go,’” she recalls.

That three-month stint cemented LaForce’s desire for international work. He flew to Delhi and began working with the
Smallpox Eradication Program in India. When a major outbreak developed in Bangladesh, he flew to Dhaka, the capital.

Bangladesh is a mostly flat country in the middle of the Ganges Delta, prone to catastrophic floods and cyclones. It is one of the world’s most densely populated and poorest countries. LaForce would replace an epidemic intelligence officer who had just left the remote northern Kurigram Subdivision.

Although there were no automobile roads in the area, he was to travel by Land Rover. For the final leg of his journey, he put the vehicle on two lashed-together boats on a river. His first task upon arrival was to find an assistant. He found Zoha, a young man who knew some English and could drive. Together they visited cases that had been identified by a motorbike surveillance team. They also gathered information on each patient’s contacts and made sure they got immunized. They explained the program to patients and village elders and hired house guards to prevent new contact with isolated patients.

Communication was practically nonexistent. LaForce touched base with officials in Dhaka by a radio hooked up to his car battery, and his family did not hear from him. In charge of all supplies, including petrol, he became a supply sergeant as well as doctor and detective. He was also the “bag man,” in charge of the money to pay helpers in the villages. He got used to eating with his hands—basically tomatoes and rice—and lost 15 or 20 pounds. But he never failed to make nightly entries in a diary, under the light of a kerosene lamp.

At times, preventing contact between infected and healthy people required strong measures. In a 2009 interview with “Global Health Chronicles,” LaForce compared his work to a military campaign. “These were essentially military rules. Expediency, getting the job done… I tried to be kind, but sometimes I wasn’t.”

Dr. Stanley Foster, then head of the program, recalls LaForce as a field general who worked extremely well with his in-country colleagues but was tough and intense. “If someone said there were no cases in a particular village, and he went there and found cases, he was not very happy. He was a leader from behind. He worked hard and inspired the people who worked under him by that example,” he says.

A Philosophical Mind

LaForce’s success in surmounting cultural and language differences to accomplish big goals can be attributed to his basic beliefs and education. He is convinced of the inherent worth and dignity of each individual, and he communicates that respect by showing curiosity about their jobs, their skills, and their hopes.

“People have a right to decent health. That belief creates its own piston for seeing that it gets done,” he says. “We should live in a just world. Having a potential good that you know should be delivered, and it can’t be delivered economically—this is unjust.”

LaForce had weighed such issues as an undergraduate with a philosophy minor. Besides underlying his compassion and drive, his philosophical nature allows him to put strange experiences in perspective. It may have helped him when he was detained as a suspected money smuggler for the better part of a day— an experience he reflects on as being formative.

“It was a lesson to me in terms of saying, Oh everything’s fine, we’ve done this great job, and the next thing you know I have these police officers with a couple of machine guns that look pretty serious…” He considers it a profound experience in the culture of a people who are desperately poor but proud and intelligent. “They taught me a lot about myself. We have these strange fantasies about ourselves: we’re wonderful, we’re great; we’re not. And as I told Stan Foster before I left Bangladesh, the experience there taught me that I’m not as nice as I thought I was. I think that sort of insight has been incredibly useful to me.”

Years later, while living in France and working at WHO headquarters in Geneva, LaForce enjoyed walking in the footsteps of Voltaire. He knows the philosopher’s works and history and uses terms like Kierkegaardian, as in the “Kierkegaardian leap of faith” he made when, in 1989, he amazed colleagues by resigning from a tenured faculty position to focus on global health. He reads Sartre for fun.

An education in history and philosophy and the other liberal arts is a base that allows you to look at a variety of problems without being a specialist, he says, and contribute something new, something innovative. “History and philosophy matter.”

Christmas in April

After working on the Smallpox Eradication Program, LaForce built his stateside resume, serving as head of medicine at the V.A. Hospital in Denver and joining the medical faculty of the University of Colorado and the University of Rochester. His three daughters grew up in Colorado, although they spent a year in Switzerland while their father was on academic sabbatical with the Expanded Program on Immunization at WHO headquarters. Throughout the 80s and 90s, LaForce was frequently on assignment with WHO and the Agency for International Development (USAID) in Asia and Africa.

Even now, says Nancy LaForce, “We have Christmas when we can get together. We’ve had it in August, February, April and October.” She calls herself the proverbial pretzel: flexible.

When the administrative demands of academic work crowd- ed out the time he was able to spend on research and public health assignments, LaForce took stock of his priorities and made a change. He departed from academia, and for two years he directed USAID’s child survival program.

In 2001, he was offered the opportunity to lead a major fight against one of the world’s greatest health threats: the recurring scourge of Group A meningococcus in Sub-Saharan Africa. He was recruited to direct the Meningitis Vaccine Program (MVP), a partnership between WHO and PATH. The project was created through a $70 million grant from the Bill & Melinda Gates Foundation with the goal of eliminating epidemic meningitis in the 25 countries where its rates are highest.

“He’s the Customer.”

Repeated epidemics of meningitis have plagued the so-called “meningitis belt” for a century. Unless antibiotics are available and used quickly, Marc LaForce explains, the death rate is high. Permanent disability afflicts a large number of survivors.

“The impact of the disease is such that an epidemic can quickly turn into a social, human and economic disaster for the affected countries,” he says.
A major epidemic in 1996-1997 stoked the public health community’s interest in developing a meningitis A vaccine that would be appropriate for the specific strain of the bacteria and affordable for Africa—a tall order in a profit-driven world with countless humanitarian needs. LaForce’s job was to forge and foster partnerships that could make it happen.

The MVP team worked with public and private international partners, including companies that could develop technology and supply materials. The vaccine was made by a generic drug maker in India at just 50 cents a dose, far less than it would cost with major vaccine manufacturers in the U.S. or Europe. The whole drug development process cost less than a tenth of what it would cost in the States. Preclinical development finished in 2004, and clinical trials followed in India and Africa.

LaForce has managed the project in the lab, in the office, and on the ground. He knows that it costs an African family the equivalent of three months’ income to have a case of meningitis, and he has seen families sell their patrimony—their front door, the last thing that goes—to recover from the loss.
In Burkina Faso in 2007, he had an experience he will never forget, one that helps explain his dedication. He met Jean-Francois, a smart, strapping 18-year-old who was the eldest of six children. “This young man had unlimited potential. I saw him on day seven of his hospitalization when it was clear that he was now stone deaf,” LaForce recalls. “I remember the attending physician telling his mother, “Being deaf in Africa is not easy…”

Later, sitting in his office in France, he started to wonder how Jean-Francois was doing and called a contact in Burkina Faso. He got sad news: the young man’s family was in mourning. While he was playing soccer with his siblings, the ball rolled into the street. Jean-Francois followed the ball and never heard the truck that struck and killed him.

“I started to cry,” says the doctor. “I vowed that I’d do whatever was required. We had to press on.”

The MVP director has an enlarged photograph of just such a young man at PATH headquarters. He tells all visitors, whether they are doctors, bureaucrats or philanthropists, “Whatever you decide, it has to be good for him. He’s the customer.”

Making History

After almost a decade, despite skepticism and regula- tory hurdles, MenAfriVac was licensed and prequalified for use. In December 2010, 11 million young people in Burkina Faso, Mali and Niger were vaccinated for meningitis in 12 days—an unprecedented feat. WHO surveillance teams gathered data in the following weeks.

Each week, no cases were found. In spite of receiving weekly updates, LaForce returned to Burkina Faso last March, the height of the epidemic season, to see the results for himself.

He was a happy man: “The hospital wards were empty.” In the 2010-2011 meningitis season, Burkina Faso confirmed just four cases of meningitis A. Niger reported four cases and Mali none, ac- cording to WHO. To date, close to 20 million have been vaccinated. The campaign now targets Cameroon, Chad and Nigeria, followed by Benin, Ghana and Senegal.

If each country can find sufficient funds to co-finance the campaign, it will be extended to all 25 countries in the meningitis belt by 2016, according to the Global Alliance for Vaccines & Immuni- zation. If the vaccine is introduced throughout the meningitis belt, LaForce says, it can prevent more than a million cases over the next decade—and free up more than $350 million that would otherwise be spent on medical costs.

His great hope is that besides relieving the pain and terror of meningitis A for people like Jean-Francois, MVP will provide a model that can be replicated in other countries for other diseases.

Le Vieux Blanc

Even on a 110-degree day in Africa, LaForce wears a businesslike button-down shirt, never shorts. He might wear sunglasses, but no hat. When it’s really hot, he unbuttons his collar and rolls up his sleeves.

“I’m very traditional. I overdress for everything,” he says. But he seems to enjoy being informally known in African villages by a nickname, “le vieux blanc” (old white man).

At 72, he feels he may finally retire—or semi-retire—but only once he sees the results of one more vaccination cycle. He hates to be idle. He loves a challenge and has no trouble finding it. He paraphrases Voltaire, saying, “When you grow old, you should cultivate your garden.” His “garden” is what’s nearby: he’d like to teach physical diagnosis as a volunteer faculty member and do carpentry projects at his house in the Blue Ridge Mountains. He’s no amateur. He has built temperature-controlled wine cellars, docks and a rail system for his boat. He may pull out his field diary and write about his experiences.

“I’d have been very happy being a carpenter, or an electrician. It’s all so logical,” he says. He pauses.

“I would like to build a box. A perfectly square one with a lid that fits. It’s really hard to do.”

Updated, September 2015
Dr. LaForce was invited to give the 2015 Academic Convocation address. His talk, titled "An Anselmian Reflects: Distributive Justice and International Childhood Immunization," examines global vaccination activities over the last 30 years from the perspective of infant immunizations as a health right, as well as explores the successful expansion of global vaccine coverage as a concrete example of distributive justice.